Wednesday, June 29, 2011

After one full month of enforcement, New York City's park smoking ban has resulted in the grand total of one ticket, according to an article in the Daily Mail.

According to the article: "It was supposed to be sweeping legislation covering 1,700 parks and 14 miles of coastline. But New York’s ban on smoking in public places has been branded an 'absolute joke' after just one ticket was issued in the first month of the law coming into force. Newly-released data shows that since May 23, around 700 people have been approached by cops for lighting up where they shouldn't have done. Of those just one has actually been given a ticket - and he was a photographer who was goading officers into doing so." ...

"Ida Sanoff, from Brighton Beach, Brooklyn, said: 'The new smoking law is an absolute joke.' She said: 'I have asthma and there are days when I've had to move my chair three times because people, sometimes in groups, sat down near me and started smoking like chimneys. She told the Wall Street Journal that she has even seen people selling cigarettes on the beach since the ban came in. 'It doesn't make sense to put a law into place without any way of enforcing it. Why bother?' she said."

The Rest of the Story

This leads me to question the sincerity of the health activists in trying to convince us that smoking in parks is a substantial public health hazard that is causing such significant health problems that it requires government intervention.

If you believe that an ordinance violation represents a serious threat to the health of innocent bystanders, then you enforce that ordinance. If you truly believe in the cause, then you should believe in it enough to enforce it. And the most important day to enforce it is day 1. Once you set a precedent by not fining anyone, the law loses its teeth and everyone comes to understand that it is basically a show-piece, not a serious piece of health protection.

When we enforced Boston's smoke-free restaurant law the first day it came into effect, we aggressively inspected establishments and levied fines that very day. We meant business, because the pretense for the law was that it was necessary to protect the lives and health of restaurant workers. If you believe in that premise, then you must also believe that it is essential to enforce the law because lives are at stake.

Clearly, New York City health officials are not concerned that much other than comfort is at stake because they don't see smoking in a park as deserving anything more than a warning.

To be clear, I agree with those officials. However, they shouldn't have deceived us in the first place by arguing - before the law went into effect - that it was necessary to address a serious public health problem.

I think Ida Sanoff of Brighton Beach is quite right. If you're not going to enforce a law, if you don't believe in it enough to enforce it, then why enact it in the first place?

When push comes to shove, I believe that health advocates are now essentially acknowledging that this was largely a feel-good ordinance and that it doesn't address any severe public health hazard. Thus, enforcement is (rightly) not a priority.

Why weren't the health groups honest with us before the ordinance was passed?

Tuesday, June 28, 2011

A column by an anti-tobacco advocate on a San Francisco Chronicle blog argues that electronic cigarettes are being marketed in an effort to increase tobacco use and accuses tobacco companies of being behind these efforts.

According to the column: "E-cigs are only one of the latest tricks in pushing tobacco to people, and to subverting anti-tobacco education and restrictions. Unhealthy components have been found therein; the FDA is fighting to regulate them as a drug delivery device, as with regular cigarettes. The World Health Association denies that e-cigs are a legitimate smoking cessation method. Canada holds that e-cigs pose similar nicotine addiction risks and banned them. Former Governor Schwarzenegger vetoed a bill that would have banned their sale in California. They are banned in some public places in other states, and on flights. They can't be sold to minors but have been flavored with fruit and candy. The nicotine content in some e-cigs has been understated in labels and is sometimes much higher than in legitimate smoking cessation products. These supposedly "safer" cigarettes undermine secondhand smoke regulations and make them harder to enforce. And so on....

So, some open questions:

1. Are "thehealthyconsumer" and other e-cig marketing sites and advertising funded by tobacco companies?

2. Does sfgate have policy regarding accepting advertising from tobacco companies? Was this advertisement/link looked at in light of such policy?

3. Do "The Doctors" from television know that their brief 2009 segment on e-cigs is being used as marketing for the devices? If so, have they received any funding from tobacco interests?"

The Rest of the Story

Both major contentions of the commentary are not only wrong, but exactly the opposite of the truth.

First, electronic cigarettes are not being marketed to try to increase tobacco use; they are being marketed to try to decrease tobacco use by getting people off of tobacco cigarettes. The goal of every c-cigarette company is to encourage smokers to switch from tobacco cigarettes to electronic (non-tobacco) cigarettes. The fewer tobacco cigarettes the smoker uses, the more money the e-cigarette companies make. So their success is directly tied to the degree to which they are able to lower tobacco sales.

Research, such as my own study published in the American Journal of Preventive Medicine, has documented that electronic cigarettes decrease tobacco use, rather than increase it. The majority of e-cigarette users cut down on the number of tobacco cigarettes they smoke and a proportion are able to quit smoking entirely. There is no evidence of any significant use of electronic cigarettes by youth or nonsmokers. Thus, I do not understand how one can claim that electronic cigarettes are designed to increase tobacco use. The truth is just the opposite. Electronic cigarettes represent a threat to tobacco sales.

The second major contention of the commentary - its accusation that Big Tobacco is behind the marketing of electronic cigarettes - is also false. None of the current electronic cigarette companies - producers or distributors - are associated with tobacco companies. In fact, they are competing directly with tobacco companies (and pharmaceutical companies) for profits.

Given the novelty of these devices and the limited research on their safety and effectiveness, there is plenty of room for healthy debate about the proper role for electronic cigarettes in smoking cessation strategy. However, that debate must be based on the truth - on factual evidence - not on a "pack of lies."

Monday, June 27, 2011

On June 16, the Food and Drug Administration (FDA) warned the public that Chantix appears to be associated with a small, but significant increase in heart attacks among patients with existing heart disease treated with the drug for smoking cessation.

According to the FDA's statement: "The U.S. Food and Drug Administration (FDA) is notifying the public that the smoking cessation aid Chantix (varenicline) may be associated with a small, increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease. This safety information will be added to the Warnings and Precautions section of the Chantix physician labeling. The patient Medication Guide will also be revised to inform patients about this possible risk. FDA reviewed a randomized clinical trial of 700 smokers with cardiovascular disease who were treated with Chantix or placebo ... Cardiovascular adverse events were infrequent overall, however, certain events, including heart attack, were reported more frequently in patients treated with Chantix than in patients treated with placebo."

While the statement cautions that physicians must weigh the benefits of quitting smoking versus any increased risk of cardiovascular events that may be caused by Chantix, the study data do not reveal any net benefit of Chantix-associated smoking cessation. If reduced heart attacks associated with smoking cessation outweighed the increased heart attacks caused by Chantix, then there should have been a lower incidence of non-fatal heart attacks in the treated (Chantix) group. This was not the case. The non-fatal myocardial infarction rate over the one-year follow-up period of the study was 0.9% in the placebo group and 2.0% in the Chantix-treated group.

Thus, within this one year period, the clinical trail failed to demonstrate any net benefit of Chantix in terms of preventing heart attacks within the first ten months of quitting smoking using Chantix.

The Rest of the Story

The rest of the story is that while each of the following groups has called for the removal of electronic cigarettes from the market because of the hypothetical possibility that these devices could have adverse effects - but in the absence of even a single reported serious adverse event - none of these groups have similarly called for the removal of Chantix from the market, nor have they even informed their constituents on their web sites about this new critical information about Chantix-associated severe side effects, even though there are now hundreds of reported suicides and a number of heart attacks associated with Chantix use.

The groups are: the Campaign for Tobacco-Free Kids, American Cancer Society, American Heart Association, American Lung Association, Action on Smoking and Health, The American Academy of Pediatrics, and the American Legacy Foundation.

These groups have three things in common:

1. Each has called for the removal of electronic cigarettes from the market, despite the absence of even a single severe adverse reported event

2. Each has refused to call for the removal of Chantix from the market, despite the presence of hundreds of cases of suicides associated with the use of the drug, and now with clear evidence of an increase in heart attacks associated with drug use and no net benefit of the drug in one-year reduction in myocardial infarction

3. Each has refused (from the best of my internet review) to even display the information from last week's FDA statement about the risks of Chantix.

Actually, the groups have an important fourth thing in common:

4. They all have or have had financial associations with Pfizer, the manufacturer of Chantix.

I am not in this commentary calling on the removal or non-removal of Chantix from the market. What I am calling for, however, is consistency in the way in which public health groups evaluate and analyze public health policy issues. Systematic bias should not be a part of the public health evaluation of policy, and such a systematic bias should never enter into the picture because of financial conflicts of interest, especially ones which are not readily disclosed.

Wednesday, June 15, 2011

Outdoor smoking bans in wide-open places like parks are spreading rapidly. Today, I report that San Clemente (California) is considering an ordinance that would ban smoking in all parks.

According to an article in the Orange County Register, smoking is already banned "on the city's beaches, on all city-operated trails and in designated canyons" and "within 25 feet of a playground."

City officials met last night to discuss the ban. As of the time this article went to press, I had not yet heard the result of last night's meeting.

The Rest of the Story

It is not clear what the justification for this proposed policy is. Since smoking is already banned on all beaches and on all city-operated trails and in canyons and within 25 feet of a playground, what is the substantial public health hazard that necessitates this policy?

As I argued in my op-ed in the New York Times: "in trying to convince people that even transient exposure to secondhand smoke is a potentially deadly hazard, smoking opponents risk losing scientific credibility. The antismoking movement has always fought with science on its side, but New York’s ban on outdoor smoking seems to fulfill its opponents’ charge that the movement is being driven instead by an unthinking hatred of tobacco smoke. That, in turn, could jeopardize more important fronts in the antismoking fight, in particular the 21 states that still allow smoking in bars and restaurants."

Tuesday, June 14, 2011

Most of the research leading anti-smoking advocates to view nicotine replacement therapy (NRT) and medications like Chantix as effective for smoking cessation involves clinical trials in which subjects received intensive interaction with research staff, including counseling, interviews, and repeat phone calls. However, in real life (outside of the setting of clinical trials), the situation is very different. Some have therefore questioned whether the effectiveness rates of NRT and Chantix in clinical trials is indicative of their likely actual effectiveness as they would be typically used on a population basis.

New research published online ahead of print in the journal Nicotine and Tobacco Research suggests that in more real-life settings, the effectiveness of Chantix is far below that which has been previously reported in clinical trials. While six-month abstinence rates with Chantix as high as 33.5% were reported in the drug's original FDA approval studies, the current study reports only a 14% six-month point-prevalence (7-day) abstinence rate with Chantix (compared to 7% for placebo).

The population in this study consisted of smokers who wanted to quit but had no quit attempt planned in the next month.

The Rest of the Story

In the current study, subjects were provided with just 8 support/counseling sessions compared to 19 in the original Chantix clinical trial. As John Polito points out, the real question is what the six-month abstinence rate would be for the use of Chantix without any support and counseling sessions, as is the case most typically with the population-based use of this drug for smoking cessation.

This research suggests that as the number of support sessions falls and the intervention approaches a real-life situation, the effectiveness of the medication falls quite drastically.

Of note, the same lead study author has previously reported a six-month abstinence rate of only 7% for over-the-counter use of nicotine replacement therapy. This is again much closer to the real-life situation than many clinical trials.

The rest of the story is that tobacco control advocates and researchers are grossly over-estimating the effectiveness of existing, FDA-approved pharmaceutical smoking cessation aids such as nicotine replacement therapy and Chantix because the clinical trial setting with intensive intervention, counseling, and support does not simulate the real-life situation in which most of the population is using these drugs.

It's quite interesting that many tobacco control researchers are questioning the use of electronic cigarettes because they have not been shown to be effective for smoking cessation, yet these same researchers have no problem recommending for widespread use an approach that appears to fail at least 93% of the time.

(Thanks to John Polito for the tip, and for the many insights that I incorporated into this post).

Monday, June 13, 2011

In an article published online ahead of print in the journal Tobacco Control, a group of tobacco control researchers are attacking electronic cigarette companies for promoting their products by partnering with the entertainment industry and celebrities (see: Grana RA, Glantz SA, Ling PM. Electronic nicotine delivery systems in the hands of Hollywood. Tobacco Control, June 9, 2011).

The article decries the use of an electronic cigarette by Katherine Heigl during her appearance on "The Late Show with David Lettermen," where she stated that she was using the device to quit smoking. It also decries the featuring of electronic cigarettes as a health innovation on the talk show "The Doctors."

According to the article: "In the past, the tobacco industry has partnered with entertainment executives and celebrities to employ several strategies to promote their products in television, movies and popular culture, including cross promotion, product placement and systematic supply of free products to entertainment industry members. It appears that the ENDS [electronic nicotine delivery systems] manufacturers are adopting similar tactics. Given the substantial research demonstrating the effect of viewing smoking in the movies on adolescent smoking initiation, the addictive nature of nicotine and the lack of regulatory assurance of their quality or safety, it is important to keep ENDS, and other similar products, from being sensationalized through the use of celebrity promotion or product placement in movies or other entertainment media."

The Rest of the Story

First, it is not clear to me that this situation is analogous to the tobacco industry's partnerships with Hollywood to promote cigarette smoking because I am aware of no evidence that these depictions of vaping on television were paid for by electronic cigarette companies. Is it not possible that Katherine Heigl decided to demonstrate vaping on television on her own, rather than as a result of having received an electronic cigarette company payment to do so? And is it not possible that the physicians on "The Doctors" actually believe that electronic cigarettes are an important health-related innovation, rather than that they were paid off by e-cigarette manufacturers to promote these devices?

Since the article presents no evidence to support its contention that the electronic cigarette companies had a hand in either of these events, I find its conclusion that the electronic cigarette companies are behind these depictions to be unsupported and therefore inappropriate.

More importantly, though, the paper seems to miss the point. The promotion of electronic cigarettes in the entertainment media and by celebrities is a bad thing only if these devices are actually ineffective for smoking cessation and/or significantly harmful to users. If they are much less harmful than cigarettes and they are helping people to quit smoking, then the promotion of this product in the entertainment media and by celebrities is a great thing and it could save thousands of lives.

The best available evidence at the present time supports the conclusion that electronic cigarettes are much safer than cigarettes and that they are helping thousands of ex-smokers to stay off tobacco cigarettes. Thus, it is most likely the case that the promotion of electronic cigarettes on entertainment television is a good thing because it may be stimulating smokers to quit by trying these unique devices.

In essence, these researchers are criticizing an intervention that is encouraging people to quit smoking. Why would we want to do this? Isn't smoking cessation something we should be encouraging, not attacking?

The problem, of course, is that smokers are not quitting the way we want them to quit. It is not about quitting smoking, it is about quitting smoking the right way. Our way. The way that lines our pockets because of the numerous financial contributions that pharmaceutical companies make to anti-smoking organizations. The way that expert panel members who received payments from these pharmaceutical companies recommend. The way that is least effective because the success rate of NRT treatment is so dismally low.

I guess if it threatens the coffers of anti-smoking organizations, then it's not the right way to quit. And if it simulates smoking - even if much safer - it's definitely not the right way to quit, no matter how effective it may be.

Thursday, June 09, 2011

According to an article in the New York Times, investigators running a trial to determine whether CT screening for lung cancer is effective in reducing mortality rates cannot locate 90% of the informed consent forms, casting doubt on whether consent was appropriately obtained for tens of thousands of patients who were subjected to significant quantities of radiation.

According to the article: "In medical experiments on human beings, every patient must sign an “informed consent” form acknowledging the risks, and researchers are required to keep track of those statements. But the doctors who conducted a controversial, widely publicized lung cancer study involving more than 50,000 patients at numerous hospitals were unable to locate 90 percent of the consent forms, according to a confidential review provided to The New York Times. The finding casts further doubt on a clinical trial that made headlines in 2006 when it concluded that fully 80 percent of lung cancer deaths could be prevented through wide use of CT scans."

A scientific reviewer who was called in to assess the situation is quoted in the article as stating that he has no confidence that informed consent was actually obtained for tens of thousands of patients: "One reviewer, Dr. David P. Carbone, a professor of medicine and cancer biology at Vanderbilt, said in an interview that he and the other reviewers never found out 'whether these consents were obtained and lost or whether they weren’t obtained at all.'"

One medical journal that published work from the research - entitled the International Early Lung Cancer Action Program (ELCAP) - stated that it would be forced to retract that article if the consent forms cannot be located: "Dr. Bruce A. Chabner, director of clinical research at Massachusetts General Hospital Cancer Center and editor in chief of The Oncologist journal, said he would ask Weill Cornell for an explanation of the problems outlined in the 2008 scientific review, as well as a follow-up to the report. His journal has published research by Dr. Henschke, and 'if we find there was no informed consent for those patients, the paper would have to retracted,' he said."

The Rest of the Story

This appears to be a very serious violation of responsible research conduct. It is particularly troubling because this is not a minimal risk study. Subjects in the ELCAP trial are subjected to significant doses of radiation, which itself presents a small cancer risk. If subjects were entered into the trial without informed consent, this would be a major ethical breach.

A single CT scan can expose a patient to the equivalent amount of radiation as up to 442 chest x-rays. Some researchers have estimated that radiation delivered by CT scans in one year will result in a total of 29,000 future cases of cancer. Thus, the risks to which patients were exposed in the ELCAP trial are not trivial and the failure to be able to document informed consent is a major problem.

Long-time readers of the Rest of the Story may recognize that this is not the first time this research has been the subject of a commentary. The institution where the bulk of the research was conducted - the Weill Cornell Medical College - was awarded my Pants On Fire Runner-Up Award in 2009 for falsely claiming that an apology was made for its investigators' failure to disclose a significant conflict of interest in their article on the role of low-dose CT scans in screening for lung cancer.

That financial interest: the principal investigator of the study receives royalties from General Electric on intellectual property she invented which involves the use of CT scanning for early diagnosis of lung cancer, intellectual property which was licensed to General Electric.

Thus, the investigator stands to gain financially if CT scanning is found to be effective in reducing cancer mortality. I wonder if this fact was disclosed to study participants. My personal view is that it would have been unethical not to inform patients of this financial conflict of interest.

Sadly, the rest of the story is that the researchers cannot even document that informed consent was obtained, much less that the financial conflict of interest was disclosed to potential study participants.

Wednesday, June 08, 2011

Today, I am going to put forward the argument that Globalink (the international tobacco control list-serve) would be better called GlobalGroupthink. It is a perfect example of the groupthink phenomenon which has gripped the tobacco control movement and which I believe threatens the integrity and scientific credibility of the movement.

When I first joined Globalink, I did so because I believed it would be a valuable way for me and other tobacco control researchers and advocates to share critical research findings, discuss scientific and policy issues, and obtain thoughtful feedback on ideas to advance the tobacco control field.

What I discovered is that Globalink serves precisely the opposite functions. It is a mechanism for preventing critical discussion of research, science, and policy issues in tobacco control. It serves to stifle thoughtful discussion of ideas, suppresses dissenting opinions, and plays out as a forum for malicious individual attacks against researchers, advocates, or citizens who dare to go against the mainstream opinions within the tobacco control movement.

I found this out in an interesting way. We were having a discussion on Globalink about employer policies to refuse to hire smokers. While many of the advocates spoke out in favor of such policies, a small number opposed them. It was suggested that we take an informal vote in order to get a sense of how opinion split on the issue. I thought this was a fair idea and would have helped us to get a sense of where tobacco control advocates’ positions split on the issue.

However, a number of advocates argued vehemently against taking a vote, arguing that if information were made public showing that a significant number of tobacco control advocates opposed these policies, it would give ammunition to “our opponents.” This point of view carried the day and the vote was quashed.

This move not only prevented a vote and ensured that we would never know the extent of opposition workplace smoker bans, but it also sent a message to everyone on the list-serve that support of such bans is the “official” dogma of the movement and that anyone who dares express disagreement to such policies is viewed as the “opposition.” Thus, this move made a clear statement that expressing disagreement with the idea of refusing to hire smokers was essentially heresy and that by doing so, the dissenter would be cast out of the movement and be viewed and treated as the opposition.

This is but one example, but it demonstrates how groupthink operates on Globalink. For all I know, it Is very possible that the majority of Globalink members actually opposed the refusal to hire smokers. However, because it was made clear that expressing such an opinion would be viewed as heresy, very few were willing to speak out. This, in turn, created the false perception that almost everyone on Globalink supported such measures. In effect, groupthink makes it possible for a group of people who almost all oppose a particular measure to come to the conclusion that they uniformly support such a measure.

I was soon to found out the extent to which groupthink dominates Globalink. I submitted a comment in which I suggested that the strength of scientific evidence supporting the conclusion that smoking bans lead to a dramatic, immediate reduction in heart attacks was not as strong as being asserted by many anti-smoking groups. Instead of responses that took issue with my interpretation of the scientific evidence, I was met with a defamatory personal attack: an accusation that I am a “traitor” who has gone to the other side and who now takes tobacco industry money.

In addition to personal attacks, there were also calls for me to be removed from Globalink for having the gall to express disagreement with one of the most entrenched pieces of dogma in the movement: that all research demonstrating adverse effects of secondhand smoke or positive effects of bans must be correct.

While most people are deterred by these personal attacks and defamatory accusations, I remained undeterred, somehow withstanding getting pummeled by my own colleagues. I continued to express my opinions, which from time to time, differed with those of the mainstream. Eventually, the inevitable happened. Globalink and its members had enough of my willingness to express disagreement, and I was expelled from the list-serve.

During my time on Globalink, I witnessed vicious personal attacks against any and all opponents of tobacco control policies, including private citizens who had no affiliation with tobacco companies. It was a forum for mud-slinging against anyone who dares to disagree with “our” point-of-view on the issues.

One of the characteristics of groupthink is that by insulating the group from criticism or differing opinions, the scientific rigor and integrity of the group gradually dissipates. Without being subject to challenge, scientific arguments and evidence begin to fail. No reputable scientist insulates herself from criticism or challenge. In fact, it is by subjecting ourselves to constant challenge that scientists are able to ensure the quality of their work and the accuracy of their conclusions. The very best scientists actually try to knock down their own arguments and do not draw conclusions until they are able to address every reasonable alternative hypothesis.

This process is not possible with groupthink. And this is why groupthink destroys the scientific integrity and credibility of social movements.

I witnessed an illusion of invulnerability regarding the scientific evidence related to secondhand smoke and the effectiveness of smoking bans. There can be no scientific study reporting adverse effects of secondhand smoke that is weak or wrong. There can be no scientific study reporting benefits of smoking bans that is weak or wrong. Thus, anti-smoking groups are willing to take great risks with respect to the claims they are willing to make about the effects of brief secondhand smoke exposure and about the immediate cardiovascular benefits of smoking bans. The normal carefulness that would temper extreme claims largely does not operate when it comes to this aspect of the tobacco control movement.

"2. Collective rationalization – Members discount warnings and do not reconsider their assumptions."

The perfect example of this is policy regarding electronic cigarettes compared to Chantix. Anti-smoking groups have been unwilling to reconsider their assumptions regarding the role of harm reduction in tobacco control, even though electronic cigarettes are not manufactured by tobacco companies, contain no tobacco, and involve no combustion. Anti-smoking groups have also discounted warnings regarding the life-threatening effects of Chantix and thus find themselves in the absurd situation of calling for a ban on electronic cigarettes, which have killed no one, while promoting the continued availability of Chantix, which has been associated with more than 200 suicides. Anti-smoking groups are not willing to reconsider their basic assumptions.

"3. Belief in inherent morality – Members believe in the rightness of their cause and therefore ignore the ethical or moral consequences of their decisions."

Anti-smoking groups too often justify unethical behavior, personal attacks on others, or receipt of funding from corporations with conflicting interests by arguing that the cause is a good one, so these pitfalls are justified. A perfect example of this was the American Legacy Foundation's argument that its taking tobacco money to fund anti-smoking ads was acceptable because the cause was a good one, but that nobody else could take tobacco money because by doing so they were contributing to the public relations work of the evil tobacco companies.

Anyone who opposes tobacco control dogma is viewed as the enemy and is personally attacked. Globalink is loaded with these personal attacks on opponents. The opponents are viewed in a stereotypic way and factual evidence is not needed to support attacks on these individuals.

"5. Direct pressure on dissenters – Members are under pressure not to express arguments against any of the group’s views."

My expulsion from Globalink, as well as the efforts to directly suppress opposing viewpoints are perfect illustrations of this fifth characteristic of groupthink.

"6. Self-censorship – Doubts and deviations from the perceived group consensus are not expressed."

I cannot tell you how many times I would receive phone calls after one of my posts to Globalink thanking me and telling me how much the individual agreed with me and was grateful that I had the courage to express my dissenting opinion. However, very few of these advocates were willing to share their opinions publicly. Self-censorship is rampant in the tobacco control movement.

"7. Illusion of unanimity – The majority view and judgments are assumed to be unanimous."

The effect of this self-censorship is an illusion of unanimity. Because dissent is discouraged or quelled and individuals do not feel free to disagree, an illusion of unanimity is created.

"8. Self-appointed ‘mindguards’ – Members protect the group and the leader from information that is problematic or contradictory to the group’s cohesiveness, view, and/or decisions."

The actions of the Globalink leadership to expel me when my opinions threatened the group by being contradictory to its views demonstrate this characteristic in action.

The rest of the story is that in many ways, Globalink is a textbook illustration of the phenomenon of groupthink in practice. All eight of the characteristics described by Janis are present and they work together to create a group that is largely insulated from outside opinion and where groupthink therefore flourishes.

Monday, June 06, 2011

In a display of the reverse logic that seems to pervade the tobacco control movement these days, Australia has seized and destroyed 70 packages of relatively harmless electronic cigarettes, while allowing millions of deadly, real ones to continue through to consumers.

According to an article in the Morning Bulletin, these dangerous products that were seized have the following scary properties: "[they] emit a harmless water vapour to give the feel of smoking but don’t contain the bad odour, carbon monoxide, tar and ash of a normal cigarette."

The Rest of the Story

Yesterday, I demonstrated the reverse logic of health officials in Linn County (Iowa), who are considering banning dissolvable tobacco products to "protect youth." Yet the truth is that youths don't use dissolvable tobacco products and the ordinance exempts the very products that the youths of Linn County do use.

Today is another demonstration of the reverse logic prevalent today in tobacco control. Health officials in Australia have banned a relatively safe product that delivers nicotine without thousands of toxins and carcinogens, yet they are allowing the real cigarettes - which deliver more than 60 known carcinogens - to remain unchecked.

Check out this logic:

Number of deaths from cigarettes each year in Australia: More than 15,000Number of deaths from electronic cigarettes each year in Australia: 0

Status of cigarettes: LegalStatus of electronic cigarettes: Illegal

This logic makes no sense. If anything, what it does is help to protect entrenched tobacco industry sales. The tobacco industry could ask for no greater help than to shield itself from the threat of losing business due to electronic cigarettes.

Apparently wanting to make sure that kids in Linn County, Iowa will continue to have access to their tobacco product of choice - cigarettes - health officials in that county are urging the County Board of Supervisors to pass a law that bans the sale of tobacco products, but exempts the most popular types of tobacco products among kids: cigarettes and traditional smokeless tobacco products like snuff and chewing tobacco.

In fact, the only type of tobacco product for which a ban is recommended by county health officials is dissolvable tobacco products (like Ariva and Stonewall), which are exceedingly unpopular among youths.

Ironically, the entire premise of the proposed policy, according to health officials, is to "protect youth."

According to an Eastern Iowa Healtharticle: "Linn County Public Health received a $2 million, two-year Communities Putting Prevention to Work grant last year through the U.S. Department of Health and Human Services to target tobacco policies."

The Rest of the Story

If this is how the $2 million of federal taxpayer money is being used, then it is being spent in exactly the opposite way that it should.

This policy targets precisely the least popular type of tobacco product among youth and specifically exempts the most popular tobacco product: cigarettes. Thus, the proposed ordinance does nothing to reduce youth tobacco use in Linn County. It does, however, penalize smokers who may be trying to quit with the use of Ariva or Stonewall.

A study published last year in the journal Nicotine and Tobacco Research demonstrated that the use of Ariva/Stonewall "led to a significant reduction (40%, 95% CI: 24%–55%) in cigarettes per day, no significant increases in total tobacco use (cigarettes + Ariva/Stonewall; p > .05), and significant increases in two measures of readiness to quit, either in the next month (p < .001) or within the next 6 months (p = .04), as well as significant increases in self-efficacy to quit smoking (p < .001)."

The researchers conclude: "this study suggests a strong need for a large prospective randomized clinical trial to more accurately assess the long-term viability of smokeless tobacco use as a method for cessation induction among unmotivated smokers."

I guess they won't be conducting that trial in Linn County. There, they seem to be eager to take off the market a product which is safer than cigarette smoking and which could potentially be helping some smokers to quit, under the guise of "protecting youth." But how exactly does it protect youth to ban a product which those youth are not using? And to exempt from the ban the precise products which are most popular among those youth?

The logic among Linn County health officials is exactly reversed. This is similar to the reversed logic among national anti-smoking groups, which supported FDA tobacco legislation that institutionalizes the FDA's seal of approval for the most toxic tobacco products on the market - cigarettes - and puts insurmountable obstacles that preclude the marketing of safer tobacco products that could potentially save lives.

While Linn County received a $2 million "Communities Putting Prevention to Work" grant last year, I would suggest that this year it needs a $4 million "Communities Putting Logic to Work" grant.

Friday, June 03, 2011

In its advocacy guide to promoting outdoor smoking bans, Physicians for a Smoke-Free Canada instructs local anti-smoking advocates that all opposition to outdoor smoking bans is orchestrated by the tobacco industry. Those who advocate against such policies are not ordinary citizens, but are front groups or plants from the tobacco industry.

Speaking of initiatives to oppose outdoor smoking bans, Physicians for a Smoke-Free Canada states: "These initiatives are invariably undertaken by tobacco industry front groups or plants, not ordinary citizens. If this is happening in your community, try to follow the money and you’re sure to find the tobacco industry behind the scenes."

The Rest of the Story

According to Physicians for a Smoke-Free Canada, I must be a front group or plant from the tobacco industry because I published an op-ed opposing the outdoor smoking ban in New York City.

I challenge Physicians for a Smoke-Free Canada to "follow the money" and "find the tobacco industry behind the scenes" as they claim is "invariably" the case.

Physicians for a Smoke-Free Canada is demonstrating one of the leading pieces of fallacious dogma in the tobacco control movement: the assumption that all opposition to smoking bans is invariably orchestrated by the tobacco industry and that there is no such thing as an ordinary citizen opposing a smoking ban.

If you take part in secondhand smoke policy training in the tobacco control movement, chances are that you will be taught that all opposition to smoking bans is orchestrated by the tobacco industry, that anyone who challenges the science connecting secondhand smoke exposure and severe health effects is a paid lackey of Big Tobacco, and that any group which disseminates information challenging these health effects is a tobacco industry front group. Consequently, the a chief strategy of tobacco control is to smear the opposition by accusing them of being tobacco industry moles. And in no situation should one say anything positive about an opponent, even if true.

More importantly, if you act in opposition to this dogma, you are cast out of the movement, swiftly and with a one-way ticket. I learned this the hard way.

In 1999, a sentinel event in my career occurred which woke me up to the fact that I had in fact been brainwashed to believe these errant ideas. I wrote an article summarizing some of these ideas. In the article, I suggested that if any group opposes a smoking ban, advocates should not discuss the substance of the opponents' claims, but should instead try to discredit them by exposing their ties to Big Tobacco.

I woke up one morning to find that, without my permission, my article had been posted on the internet by Americans for Nonsmokers' Rights (ANR). Something about having my work published on the world wide web for everyone to see awoke me from my brainwashing and snapped me back to reality. Immediately, I realized that I had made a mistake. I called ANR and asked them to please change the article to reflect a clarification, in which I made it clear that I was not in fact accusing certain individuals who had challenged the severity of secondhand smoke health effects of having personally received money from tobacco companies.

To my shock, ANR refused to accede to my request, even though I was the author of the article. They responded that they did not want to say anything even remotely positive about an opponent and that they had to place their own political agenda ahead of my scientific integrity:

"we have concluded that the possible 'clarification' that you and I discussed is simply not feasible. There is a strong concensus that we do not want to post ANYTHING on our web page that can be construed as an apology or as backtracking from the position taken in the paper you wrote. More specifically, XXXXXX has convinced me that, given XXXXX's long history of attacking ETS science, it would be a mistake to state anything that would give him credence. ... I realize that your views on the matter are heart-felt and sincere, and that mere removal of your name from the paper, without more, will not be entirely satisfactory to you. But at this point ANR must put its political credibility ahead of what you consider to be your scientific credibility."

ANR then decided to completely disrespect my authorship rights and my copyright of the article, and to subsume copyright of the article for itself by publishing it on its website without my name. I never gave ANR permission to do this. What I told ANR clearly was that given its refusal to change my article as I re-wrote it, I wanted the article removed from its website. It was only when ANR refused to honor this author's request that I demanded that my name be removed from its website.

What turned out to be errant information about the nature of opposition to smoking bans was delivered to me via a systematic method of formal trainings in which these ideas were deliberately spread to me and other tobacco control advocates with the purpose of furthering the anti-smoking cause.

These ideas ran counter to my own pre-conceived and firmly held ideas about the nature of opposition to smoking bans and to challenges of the health effects of secondhand smoke. After all, I had many good friends who challenged the connection between secondhand smoke and chronic disease, so I "knew" that not everyone who challenges the science is a Big Tobacco lackey. I also had met many of the opponents of smoking bans and it never occurred to me that they were tobacco moles. Nevertheless, this wisdom was so strongly imparted upon me in the trainings (which were largely delivered by, or influenced by ANR) that I came to believe this information, even though it was at odds with my pre-conceived beliefs.

Importantly, only one perspective on this issue was presented to us in the trainings. There was no room for disagreement or challenge. These ideas were presented as scientific facts, not subject to debate. In fact, if we were to challenge the ideas, the implication was that we - ourselves - might be accused of working for Big Tobacco or receiving secret payoffs.

This dogma, however, is untrue. While it is certainly the case that most of the scientific challenges to secondhand smoke science came from tobacco industry-funded initiatives, there are a number of scientists and others who have challenged the science but are not paid by Big Tobacco to do so. The American Council on Science and Health, for example, has challenged the strength of the link between secondhand smoke and chronic disease, while acknowledging the acute effects of tobacco smoke. Martha Perske wrote some very well-researched and meticulous critiques of secondhand smoke science. I have myself challenged the claims made by many anti-smoking groups about the acute cardiovascular effects of secondhand smoke. So no - not everyone who suggests that secondhand smoke health claims have been exaggerated is a paid lackey of the tobacco industry.

Now, Physicians for a Smoke-Free Canada is demonstrating how this dogma plays out in practice. I challenge them to demonstrate that what they are instructing local advocates is true. I challenge Physicians for a Smoke-Free Canada to "follow the money" and "find the tobacco industry behind the scenes" as they claim is "invariably" the case.

This is important, because if I've received that money, I need to find it myself. Think of the things I could be doing with it if only I knew where it was.

Thursday, June 02, 2011

In response to an amendment being offered by Representative Denny Rehberg (R-MT) that would gut the FDA Tobacco Act by precluding the agency from eliminating any tobacco constituent on the basis that it increases cigarette initiation, appeal, or addiction, the Campaign for Tobacco-Free Kids has issued a press release bemoaning the effect of this amendment on the FDA's ability to eliminate menthol from cigarettes.

The press release complains that: "Among other things, the Rehberg amendment would restrict the FDA's ability to regulate the use of menthol in cigarettes. The FDA's Tobacco Products Scientific Advisory Committee in March 2011 issued an exhaustive report that concluded menthol increases the number of kids who start to smoke and reduces the number of smokers who quit. While the committee found there is insufficient evidence to conclude that menthol itself increases disease risk for individual smokers, it did conclude that menthol harms public health because it increases the number of people who smoke and the number who become sick and die as a result. Yet, under the Rehberg amendment, the FDA could not take action regarding menthol in order to prevent kids from starting to smoke or to help more smokers quit. The addition of menthol is just one example in the tobacco industry's long history of designing their products to make them more attractive to children and minorities, or more addictive and difficult to quit using."

The Rest of the Story

The rest of the story is that the Campaign for Tobacco-Free Kids has been the leading supporter of the tobacco industry's long history of designing its products to make them more "attractive to children and minorities" (through menthol cigarettes). The Campaign for Tobacco-Free Kids opposed an amendment that would have deleted the menthol exemption from the cigarette flavorings ban and thus eliminated this tobacco industry method for making its products more attractive to "children and minorities."

Let's get this straight: the Campaign for Tobacco-Free Kids worked to ensure that menthol cigarettes would remain on the market and that tobacco companies would continue to have the ability to produce and market menthol cigarettes to attract kids, especially African Americans.

What argument did the Campaign for Tobacco-Free Kids use in opposing the amendment to include menthol cigarettes in the flavorings ban? The Campaign argued that the amendment would open up a huge black market. Ironically, the Campaign for Tobacco-Free Kids advanced Lorillard's eventual argument in opposition to a menthol ban prior to the cigarette company having to even open its mouth.

The rest of the story is that the Campaign for Tobacco-Free Kids did the tobacco industry's bidding during the Congressional negotiations that led to the Tobacco Act. The most significant protection in the legislation - the exemption of menthol cigarettes from the flavorings ban - was the direct result of lobbying by the Campaign.

Moreover, even when Congress was poised to remove the menthol exemption and it clearly appeared that there existed the political will to take such an action, the Campaign played a major role in blocking such an action by swiftly and unequivocally opposing the amendment and instructing all other anti-smoking groups to do the same.

And now, the Campaign for Tobacco-Free Kids has the gall to moan and complain about the chilling effect the Rehberg amendment might have on the regulation of menthol?

Regardless of how one feels about the regulation of menthol cigarettes, the Campaign for Tobacco-Free Kids' hypocrisy is beyond comprehension. This is an organization that is so full of crap that there is literally no room to hold any more.

Wednesday, June 01, 2011

Physicians for a Smoke-Free Canada is encouraging local anti-smoking advocates throughout Canada to deceive the public in order to promote widespread outdoor smoking bans that cover wide-open areas such as parks, streets, parking lots, sidewalks, curbs and retaining walls.

Specifically, Physicians for a Smoke-Free Canada instructs local advocates to tell the public that: "Even in very small concentrations, second‐hand smoke causes immediate, short‐term and long‐term harm to people exposed to it. ... The long‐term harm can include premature death from cancer or heart disease."

Thus, Physicians for a Smoke-Free Canada is instructing local advocates to claim that even very small concentrations of secondhand smoke causes heart disease and cancer.

In addition, the physicians group is encouraging anti-smoking advocates to deceive the public about how well outdoor smoking bans are working. Advocates are told to: "Plant stories in the media about non‐smokers politely asking smokers to move to a designated smoking area or outside the smoke‐free area and smokers complying. Create the impression that the bylaw is working...".

Moreover, advocates are encouraged to conduct bogus public opinion polls in order to make it look like there is more support for smoke-free outdoor areas than there really is by driving people to these online, non-scientific polls: "What is important with any online advocacy tool is that you have to drive traffic to the site to get the numbers that you need to influence politicians."

The Rest of the Story

I'm not sure which is more remarkable:

1. The fact that Physicians for a Smoke-Free Canada is encouraging anti-smoking advocates to deceive the public in order to get smoke-free outdoor laws passed; or

2. The fact that Physicians for a Smoke-Free Canada had the chutzpah to put is advocacy manual online so that the entire world can see that the group is encouraging local advocates to deceive the public in order to get these increasingly aggressive anti-smoking policies enacted.

First, it is not true that "very small" concentrations of secondhand smoke cause heart disease and lung cancer. The evidence that secondhand smoke exposure causes these chronic diseases comes from studies of relatively high levels of chronic exposure to secondhand smoke, such as that experienced working for many years in a workplace with tobacco smoke or living for many years with a smoker. There is no evidence that merely a brief exposure to secondhand smoke, such as might be experienced in a park or on a street, is sufficient to cause heart disease and lung cancer. In fact, the effects brief exposure to secondhand smoke are reversible and one would therefore need to be regularly exposed to secondhand smoke for many years in order to develop heart disease and lung cancer.

Where are the physicians getting their information? From the U.S. Surgeon General, of course, who claimed - incorrectly and without any scientific support - that even brief exposure to secondhand smoke causes heart disease and lung cancer.

Second, it is apparent that Physicians for a Smoke-Free Canada wants local advocates to "create the impression" that the outdoor smoking ban is working by "planting" stories in the media about single episodes of compliance. There is nothing here about actually conducting an objective evaluation of the law to see whether it is working. Instead, advocates are instructed to tell the public that the law is working, whether it is or not.

Third, Physicians for a Smoke-Free Canada apparently is content misrepresenting as scientific an online public opinion poll for which the group urges advocates to "drive traffic to the site." Obviously, this isn't a scientific poll at all and should not be misrepresented as such. It certainly doesn't indicate public opinion. Instead, it indicates which side is doing a better job of driving their members to the web site.

I want to emphasize that what Physicians for a Smoke-Free Canada is doing here is antithetical to public health and to its ethical principles. We are not supposed to deceive the public by spreading misleading scientific information. We are not supposed to misrepresent as scientific a poll in which supporters have been drive to a web site to try to affect the outcome of the poll. We are not supposed to conduct bogus evaluations of public policies which have a pre-determined conclusion and then create a public impression which may be false.

In fact, objective evaluation of policies is an important part of public health practice. It is our job, and our responsibility, to objectively evaluate policies to determine whether or not they are working. It does no good to pretend that a policy is working if it really isn't. That doesn't provide public health protection to anyone. In fact, it does the opposite. It denies public health protection because it prevents action from being taken that could correct the problem.

While my readers recognize that I am not crazy about policies that ban smoking in wide-open outdoor places like parks, streets, and parking lots, my opinion here is not based on my opposition to such policies. My opinion is based instead on basic ethical principles of public health conduct. I simply do not believe that we should deceive the public to advance our policy aims.

The rest of the story is that Physicians for a Smoke-Free Canada is encouraging local anti-smoking advocates to deceive the public in order to promote smoke-free outdoor laws. I suppose that if these laws were well-justified, there wouldn't be the need to encourage advocates to deceive the public. The truth would be enough.

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.